Single Port Laparoscopic Total Colectomy With End Ileostomy in the Acute Setting

INTRODUCTION: Proponents of single port laparoscopy tend to claim improved cosmesis in elective operations as its major rationale. However minimizing abdominal wounding is especially important in debilitated patients who need acute operative intervention for acute severe pancolitis recalcitrant to medical therapy. In addition to malnutrition, systemic toxemia and iatrogenic immunosuppression, their early convalescence must include stoma education while further surgery (whether ileoanal pouch formation/proctectomy for those with ulcerative colitis or ileorectal reanastomosis/other reoperation for those with Crohn’s disease) is often needed in the intermediate term.

METHODS: Having previously developed and standardized the procedure in the semi-elective setting, we have now the departmental expertise and confidence to provide the approach on-call. In short, the operation involves placement of the single port access device at the site intended for end ileostomy formation as the sole transabdominal access. For this, we favor the Surgical Glove Port as the most ergonomically and economically advantageous device currently available. This access device is constructed table-side by inserting standard trocar sleeves into the finger tips of a sterile surgical glove. The glove cuff is then stretched over the outer ring of a standard wound protector-retractor (ALEXIS, Applied Medical) in situ at the ileostomy site trephine. Standard straight rigid laparoscopic instruments and a 30 degree lens camera are used. The operation is commenced distally with early rectosigmoid transection and then proceeds distal to proximal in a close pericolic plane using an energy sealer/divider device (Liagsure, Covidien). A transanal catheter is left in situ for 72 hours postoperatively. As it needs no specialized equipment and only two members of the expert surgical team regardless of which theatre suite is available, out-of-hours service is facilitated.

RESULTS: This approach has been considered in every patient requiring acute colectomy for pancolitis since January 2011. Of ten such patients, three had standard multiport laparoscopy (due to morbid obesity, colitic perforation with peritonitis and unstable critical systemic illness). Six patients (two females, one with Crohn’s pancolitis and five with ulcerative colitis) had their entire procedure completed by the single port approach. One other patient with ulcerative colitis needed three additional 5mm ports in addition to the stoma site single port inserted to facilitate adhesiolysis of dense adhesions (prior midline laparotomy with right nephrectomy for trauma). The mean (range) age of the patients was 43 (36-59) years while mean (range) BMI was 27 (21-28) kg/m2. All were on significant immunosuppressant/biological therapies. None had antegrade mechanical bowel preparation preoperatively. Mean (range) length of theatre time from patient entry to exit was 190 (165-210) minutes. There were no significant intraoperative complications and only two minor (Clavien Class One) postoperative problems. Modal (range) postoperative day of discharge was 4 (3-6). As only trocar sleeves are used with the glove port construct, laparoscopic access costs were reduced by 60%.

CONCLUSIONS: Single port laparoscopic total colectomy is not only feasible and effective but appears useful and beneficial for patients. In-theatre costs are not increased (in fact can be reduced versus conventional laparoscopy) and postoperative hospital stays are short.

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